Implementing two national responsibilities of the revised UNICEF/WHO Baby‐Friendly Hospital Initiative: A two‐country case study

Abstract The 2018 implementation guidance for the Baby‐Friendly Hospital Initiative (BFHI) recommends institutionalising the ten Steps through nine national responsibilities for universal coverage and sustainability. As countries adapt BFHI programmes to this paradigm shift away from traditional designation programmes, documenting and sharing policy and programme experience are critical and currently sparse. This qualitative case study included desk reviews of published and grey literature on BFHI programming, national plans and policy documents specific to the selected national responsibilities for universal coverage and key informant (KI) interviews across a range of actors. In the Kyrgyz Republic, the case study explored responsibility 5, development and implementation of incentives and/or sanctions, and responsibility 6 in Malawi, providing technical assistance (TA). In both countries, the three sustainability responsibilities (national monitoring [7] communication and advocacy [8] and financing [9]) as they relate to the universal coverage of the targeted responsibilities were also explored. Thirty‐eight respondents in the Kyrgyz Republic described approaches that were used in the health system, including BFHI designation plaques, performance‐based financing and financial sanctions. However, currently, there are no formal incentives and sanctions. In Malawi, TA was utilised for national planning and to introduce quality improvement processes. Forty‐seven respondents mostly described provisions of TA in building and strengthening the capacity of providers. More programmatic evidence to demonstrate which types of incentives or sanctions can be effective and sustained and more documentation of how TA is provided across multiple aspects of implementation are needed as countries institutionalise BFHI.


| INTRODUCTION
More than 820,000 deaths among children under age five could be prevented worldwide annually if all children were optimally breastfed. In 1991, the World Health Organisation (WHO) and the United Nations Children's Fund (UNICEF) launched the Baby-Friendly Hospital Initiative (BFHI) to address the low rates of breastfeeding globally and to motivate health facilities to support optimal breastfeeding through the implementation of Ten Steps to Successful Breastfeeding (Ten Steps) (WHO et al., 1991). Evidence shows that implementation of the Ten Steps improves breastfeeding practices, including improved attitudes and skills of health workers and changes in facility practices to support breastfeeding (Gomez-Pomar & Blubaugh, 2018;Perez-Escamilla et al., 2016;WHO, 2017). Because of the government-led results-based financing scheme for ensuring health care service quality, we chose responsibility #5 for the Kyrgyz Republic. We chose responsibility #6 for Malawi because the government has received and provided technical assistance (TA) for a number of years with partner support. We also explore efforts relevant to three sustainability responsibilities (national monitoring [7], communication and advocacy [8] and financing [9]) as they relate to responsibilities #5 and #6.

| Research questions
The case study sought to answer the following guiding questions: 1. What kind of TA are facilities receiving to comply with the Ten Steps? What TA strategies help to build competency and institutionalise the provision of TA to facilities? (Malawi) 2. What incentives or sanctions support compliance with the Ten Steps? What opportunities exist for innovation to motivate facilities to comply with the Ten Steps? (Kyrgyz Republic) 3. What efforts are underway at the national level to achieve universal coverage and sustainability of these two national responsibilities? What challenges were encountered?   The strategy provides guidance on infant feeding, including breastfeeding.

Food and Nutrition Bill
Currently before Parliament, this bill would establish a National Nutrition Council with the budget and power to oversee food safety and to set and enforce rules for the promotion and marketing of foods for infants and young children.
T A B L E 1 Selection of breastfeeding-related policies Year Title Description

1996
Order N19 The order supports exclusive breastfeeding in health facilities, including rooming-in, initiation of breastfeeding within 1 h after birth, breastfeeding exclusively and on demand until 4-6 months of age, and bans feeding infants before lactation.

2000
Adoption of BFHI The Kyrgyz Republic began working towards BFHI certification in health and medical facilities.

2008
Breastmilk Substitute (BMS) Policy The policy prohibits the unnecessary use or promotion of BMS in medical facilities.

2009
Order N8 The government adopted an eleventh step to strengthen prohibition of the use of BMS in facilities and added indicators around the Eleven Steps for routine evaluation of standard practices. (The 2019 policy reverts back to Ten Steps and this manuscript references only these ten).

2010
Order N68 The order protects, supports and promotes breastfeeding among infants in maternity hospitals and children's hospitals.

2015
Order N585 The policy on nutrition and food security. The Mother-Friendly Criteria Initiative was renamed to the Baby and Mother-Friendly Hospital Initiative.

2019
Order N1078 The order updated and expanded the Ten Steps for comprehensive care for successful breastfeeding in maternity hospitals.
where the country is the unit of analysis (Yin, 2018 KIs for both countries were a convenience sample based on securing a broad selection of opinions and experiences from the national, regional, district and facility levels, as appropriate.

| Data collection
The case study included desk reviews of published and grey  There is variation between written policies and policymaker descriptions of a national system for BFHI, compared to how facility directors and service providers experience BFHI implementation at the facility level. At the national level, there is a coordination committee, national policies and curricula; however, facility administrators and service providers were either not aware of these -Service provider and another respondent expressed the desire for the World Bank project to start up again, implying that the facility was receiving neither assessments nor financial awards.
'In 2014, we had a program supported by the World Bank to support quality of service delivery to the population, and a scorecard was used to assess the performance of each hospital on a quarterly basis.
Hospitals were paid based on the points they received.

Monitoring and evaluation
The desk review revealed protocols and assessment tools for maternal, newborn and child services and quality assurance that include aspects of BFHI. For example, the MOH checklist for quality assurance and standard protocols for managing labour, delivery and newborn care includes early initiation of breastfeeding within 30 min, skin-to-skin and rooming in. However, systematic measurement and reporting of those indicators were not described.

| Barriers and challenges
A lack of resources-financial and human-was a common challenge.
Most of the funding comes from development partners for specific activities, which is insufficient to support universal coverage of BFHI implementation (i.e., a goal of training 30,000 health workers).
'Funding shortage of transport affects delegated members to supervise, monitor, and provide technical backstopping to health facilities in their districts-as they fail to go and supervise the communities.
Morale for BFHI implementation is low-due to lack of training due to financial problems'. reported on the effect on breastfeeding support World Bank, 2020 including for maternity care services (Gergen et al., 2018), a review of 68 quality checklists used in 28 countries documented a lack of indicators related to the postpartum period . breastfeeding suggested that areas such as health facility infrastructure, supplies and staffing could also benefit from TA . Partners supporting TA introduced QI processes for the Ten Steps. Although QI approaches are common in LMICs, documentation of their use for BFHI is not (Tamburlini et al., 2020;Tibeihaho et al., 2021;Valente et al., 2021). In Spain and the United While the implementation of the management and clinical steps are critical to document, these national responsibilities comprise the enabling environment and require sharing lessons learned to improve the quality of care for mothers and newborns.

| CONCLUSION
As WHO and UNICEF no longer require facility designation to become baby-friendly, countries are scrambling with limited resources to find ways to address the national responsibilities, which are all interconnected and critical to universal coverage and sustainability. They are often choosing to maintain the certification process to some extent to achieve compliance with the Ten Steps. TA is commonly provided for competency building

DATA AVAILABILITY STATEMENT
The data are not publicly available due to privacy or ethical restrictions.

ETHICS STATEMENT
The JSI Institutional Review Board (IRB) determined the study to be exempt from human subject research oversight. The IRBs of the American University of Central Asia, Kyrgyz Republic and the National Health Science Research Committee, Malawi, approved the respective studies. All participants provided written or verbal informed consent for participation and for recording the interview.
Declining to record the interview did not affect participation.